Licence Appeal Tribunal File Number: 24-007526/AABS
In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.
Between:
Stephen Stewart
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
ADJUDICATOR:
Roderick Walker
APPEARANCES:
For the Applicant:
Kameliya Stancheva, Paralegal
For the Respondent:
Paula Thomas, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Stephen Stewart, the applicant, was involved in an automobile accident on October 5, 2022, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Certas Home and Auto Insurance Company and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline (“MIG”) limit?
ii. Is the applicant entitled to the treatment plans/OCF-18s (“plans”) for chiropractic services proposed by Toronto Medical Centre, as follows: (a) $1581.98 in a plan dated November 29, 2023; and (b) $256.35 ($1,356.35 less $1,100 approved in a plan dated November 1, 2023?
iii. Is the applicant entitled to the assessments proposed by Toronto Medical Centre, as follows: (a) $1995.32 for a psychological assessment in a plan dated September 27, 2023; and (b) $1748.05 for a biopsychosocial assessment in a plan dated September 20, 2023?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant’s injuries are predominately minor in nature and the applicant is subject to the MIG.
4The applicant is not entitled to any of the treatment plans, interest or an award.
ANALYSIS
MIG
5Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured sustains impairments that are a minor injury. Section 3(1) defines a “minor injury” as “one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”
6An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the MIG or, under s. 18(2), that they have a documented pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if they are kept within the MIG. The Tribunal has also determined that chronic pain with functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.
7The applicant in this case submits that he should be removed from the MIG on the basis of his chronic pain, and a psychological condition.
The applicant does not suffer from a chronic pain impairment and a Psychological Condition.
8I find that the applicant does not suffer from accident-related chronic pain and a psychological condition which would remove him from the MIG.
9The applicant relies on four treatment plans dated September 20, 2023; September 27, 2023; November 1, 2023; and November 29, 2023, to argue that he should not be treated under the Minor Injury Guideline (MIG). The applicant states he saw his family physician, Dr. S. Palcu, on or about October 17, 2023, for post‑accident observation. However, there are no clinical notes and records, nor any decoded OHIP entry, provided to substantiate that visit for the purposes of this hearing.
10The respondent submitted pre‑accident clinical notes and records from Dr. Palcu covering April 15, 2010, to July 10, 2019, but no post‑accident records. The respondent also provided a decoded OHIP Summary for October 5, 2019, to November 27, 2023, and an updated decoded OHIP Summary for November 27, 2023, to December 30, 2024.
11The accident occurred on October 5, 2022. The first decoded OHIP entry for the applicant appears more than one year post‑accident. The entries include: October 17, 2023 (Dr. Andrew Luke, Bowmanville – IntermedAssess), October 20, 2023 (Dr. Riaz Moola, Bowmanville – MinorAssess), and September 20, 2024 (multiple entries for Dr. P. Uju, Oshawa, including IntermedAssess and skin/subcutaneous procedures). On the evidence before me, these entries do not substantiate accident‑related injury or ongoing impairment, and some entries are clearly unrelated to the accident.
12There is a significant gap between the date of loss (October 5, 2022) and the first Treatment Confirmation Form (OCF‑23), dated August 22, 2023, completed by Dr. J. Shadi, Chiropractor, at Toronto Medical Centre. This delay undermines the assertion of continuous, post‑accident injury.
13The respondent submits that it was not served with treatment records from Toronto Medical Centre or any other provider. The materials include two referrals dated October 17, 2023, from Dr. A. Luke, one for chiropractic treatment and one for psychotherapy (anxiety). These are the only post‑accident family physician documents served. There are no corresponding clinical notes and records for that date or for any post‑accident period. I accept the respondent’s submission that there is a lack of medical records before the Tribunal.
14It is the applicant’s burden to prove, on a balance of probabilities, that his injuries, whether physical (chronic pain) or psychological do not fall within the MIG.
15In this case, the applicant relies exclusively on the four treatment plans. There are no clinical notes and records from the family physician, chiropractor, Toronto Medical Centre, or any other provider demonstrating ongoing physical pain, functional limitation, or psychological impairment. Treatment plans, by themselves, are not evidence of diagnosis, causation, or impairment. The applicant has not filed objective medical documentation to support his position.
16With respect to psychological injury, the applicant has not submitted any assessments or treatment records from a psychologist, psychiatrist, or therapist; no mental status examinations; no validated psychometric testing; and no diagnosis tied to the accident. A referral alone, particularly one that does not reference the accident and is unsupported by clinical notes, is insufficient to establish a psychological impairment that would remove the applicant from the MIG.
17Having reviewed all of the materials, I find that the applicant has not established, on a balance of probabilities, that he suffers from a physical or psychological condition arising from the accident that would remove him from the MIG. The long treatment gap, the lack of post‑accident clinical records, the limited and largely unrelated OHIP entries, and the absence of objective medical evidence together weigh against the applicant’s position.
18Accordingly, I find that the applicant has not met his onus. The applicant remains subject to the MIG.
19As I have determined that the applicant remains subject to the MIG, it is not necessary for me to conduct an analysis of whether the treatment plans in dispute are reasonable and necessary.
Interest
20No interest is awarded because no benefits are payable.
Award
21Pursuant to section 10 of Regulation 664, the Tribunal may award up to 50% of the total benefits payable plus interest if it determines that the insurer unreasonably withheld or delayed the payment of benefits. I find that since no benefits are payable, no benefits have been unreasonably withheld or delayed. The applicant is not entitled to an award.
ORDER
22On the totality of the evidence, I find that:
i. The applicant is not removed from the MIG.
ii. As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.
iii. No interest or award is granted.
iv. The application is dismissed.
Released: February 12, 2026
__________________________
Roderick Walker
Adjudicator